The provision of care is dependent upon whether a surgical service is re-established and whether a cardiology service is based in South Wales. An appraisal of these options is presented below.

THE SOUTH WALES SURGICAL SERVICE

  The changes occuring in the UK provision of care and new working hours regulations has meant that the Congenital Heart Disease Centre must undergo a major re-structuring process. Central to this process is a consideration of the surgical service.

  There are four surgical options with continuance of local cardiology:

  A.   Single Surgeon Centre

  The Royal College of Surgeons' report stated that this was not a viable option unless the Cardiff and Bristol Units merged as a single unit providing cardiology and surgery on two sites. Negotiations with Bristol have concluded that whilst Bristol would like to collaborate medically they do not feel able to undertake the surgical collaboration necessary to meet the Royal College of Surgeons' requirements for continuance of cardiac surgery in Wales.

  B.   Double Surgical Centre

  This model was put to the Royal College of Surgeons but was not given serious consideration as it was their view that the workload was too small for two surgeons and the College was not persuaded that this would be mitigated by both surgeons working together. This is also the view of the Society of Cardiothoracic Surgeons of Great Britain and Ireland.

  C.   Surgical Provision from Another Centre

  As the closest geographical centre the logical choice would be Bristol. Their surgical services have improved over recent years and they have recently made an additional surgical appointment. Currently however they do not undertake the whole range of surgical interventions. Additionally due to the current adverse publicity there is reluctance amongst Welsh patients and families to be treated in the Bristol Unit.

  D.   Surgical Provision from Several Centres

  No one Centre is equally expert in every type of procedure, nor are they constantly expert in a procedure over a long period of time. Utilising the strengths of many Centres would allow treatment of children in the Centre most expert in their particular disease and allow increased patient choice. It would require careful management to ensure the quality of the surgical service provided.

  Options A and B are now no longer viable given the Bristol Children's Cardiac Unit's decision to decline to collaborate surgically and the views of the Royal College of Surgeons and the Society of Cadiothoracic Surgeons.

SOUTH WALES CARDIOLOGY SERVICE

  It is important to decide if a locally based cardiology service for South Wales is necessary in the absence of a surgical service and if so what form it should take. Undoubtedly future cardiac care in the Principality should be excellent, minimise out of Wales referrals, ensure that when a patient requires an intervention it is undertaken in a Centre with the best outcome for their disease, provide support for paediatricians, obstretricians and cardiologists, training for junior staff in Wales and carefully audit outcomes.

  Currently the cardiology service provides for the fetus, child and adult with congenital cardiac disease, training for undergraduate and postgraduate staff and audit of activity. It also has a significant input into the provision of intensive care and children with multisystem problems who often require cardiac assessment.

  In all three options (outlined below) either Surgical Option C or D may be chosen. In either model the Welsh cardiologist would discuss patients requiring surgery directly with the surgeon enabling robust clinical decisions to be made and continued professional development. Provision of a regional paediatric intensive care and transportation service will also be necessary.

  E.   No Locally Based Service

  All cardiology and surgical services would be provided on an outreach basis by another Centre(s) with a surgical unit eg Bristol. This was the type of service South Wales received prior to the Congenital Heart Disease Centre opening in 1991. Whilst this model could provide a basic service for the Principality it is unlikely to provide the comprehensive service outlined above.

  F.   "Manchester" Style Service

  This is the service provided since cessation of surgery to the majority of paediatricians. The service requires a dedicated inpatient unit in Cardiff undertaking all emergency and elective cardiology assessments. For such a service to be sustainable it requires the full support of all paediatricians in South Wales but even given that there are grave reservations that the inpatient activity levels would be sufficient either to maintain staff skills or be cost effective.

  G.   Locally Based Supportive Cardiology Service

  Independent paediatric cardiologists would continue to provide specialist advice. No dedicated inpatient facilities would be required but access to inpatient beds would be necessary for some elective procedures. Additional outreach clinics would provide increased support and advice to paediatricians, obstetricians and adult cardiologists. Tele-medicine links would aid the assessment of patients.